Skin Deep - Clinical & Cosmetic Dermatology Blog

Skin Deep is a blog for dermatologists and skin care professionals with focus on theoretical, cosmetic and aesthetic dermatology. This blog is associated with ‘Dermatologists Sans Borders’ one of the largest curated groups of skin care professionals on facebook. If you are looking for non-technical information, please visit

Uberizing Cosmetic Dermatology

Image Credit: BEP @

Some time back, I read a story about a passenger finding it difficult to get a ride on Uber. He later realized that Uber has a two-way rating system with the passenger able to rate the driver and the driver rating the passenger. If your rating as a passenger drops, you may find it difficult to get lifts — or you may even be booted off the service entirely.

Setting up a cosmetic dermatology practice is expensive these days. A few unfair reviews on popular sites such as mouthshut could ruin your practice. There is also the risk of doctor shopping, planted fake reviews and an occasional body dysmorphic disorder patient holding a grudge on everybody. There is a growing realization that threat of an unfavorable review entitles you to premium treatment at reduced rates. Read Dr. Sunaina’s post on some common problems faced by dermatologists.

With the rapid commercialization, it is time for Uberizing cosmetic dermatology. The best way to ensure good behavior from clinics and patients is to have a dual rating system like Uber! This will help clinics to identify potential problem clients, just as patients can find cost-effective treatments. Here is such a system, FREE for everyone to use at Clinic Managers can add your services to SkinHelpDesk. Potential clients can compare services and take appointments. Both can rate each other after an appointment.

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Laser Skin Tightening: Is it Effective Against Wrinkles and Sagging Skin?

When your skin starts to wrinkle and sag, it means you're beginning to show signs of aging. Such
imperfections can often be the cause of low self-esteem in a person, and can at times make them feel too embarrassed to leave the house.

While anti-aging creams can combat aging in mild cases, those with severe  skin wrinkling need something more potent to give them back their youthful glow. For these people, cosmetic treatments such as laser skin tightening are recommended.

As with any form of treatment, medical or cosmetic, you should always have an understanding of what's involved before agreeing to partake in it. This article hopes to educate you on what laser skin tightening treatment is, and aims to assist you in making a decision as to whether it's right for you.

How Do I Know Laser Skin Tightening Will Help Me?

In most cases, medical laser treatments have strict requirements when it comes to eligibility. Laser eye surgery, for example, will only work on a handful of eye conditions.

When it comes to laser skin tightening, however, there are fewer requirements. As a guideline, your skin color doesn't matter and so won't affect the outcome of the procedure. Your age is also fairly unimportant; however, be aware, statistics show the best results usually occur within the 30-60 age group.

As for medical reasons why skin tightening won't work, that's up to your dermatologist to decide. If you have a prior skin complaint, laser surgery may not be recommended for you.

Why are There so Many Different Types of Laser Treatment?

Lasers are very diverse – much more so than people realize. They currently help with a range of things such as eye care, scar or tattoo removal, cellulite reduction, and anti-aging.

As each laser differs depending on what it's being used for, you'll receive treatment tailored to your particular problem. As lasers have the natural ability to improve skin quality, you'll be making use of a specialist device that has been employed to help you tighten up your skin and reduce wrinkling.

What makes lasers so effective is that they can easily be used on multiple body parts. Even if your sagging skin or wrinkling isn't on your face, it's not a problem in the slightest. Treatment can be performed on many areas, including the legs, stomach and arms, for example.

What Does the Average Laser Skin Tightening Treatment Plan Look Like?

While your treatment may cause you a small amount of discomfort, it shouldn't cause you any pain. Most people say they experience some warmness in their skin and feel gentle snapping sensations when they go under the laser.

Overall, treatment shouldn't take longer than an hour. That includes preparation time. However, as more than one treatment is recommended, the total amount of time you'll spend receiving skin tightening treatments will usually be a few hours in total.

After you've had several sessions of laser therapy, your skin should tighten up considerably. Unfortunately, however, there is no permanent cure for aging, so sagging skin and wrinkling is likely to reoccur at some point in the future. You can, if you wish to, repeat treatment again when this happens.

Currently, laser skin tightening is one of the most effective cosmetic anti-aging procedures available. Side effects are mild, and recovery time is minimal.

This is a sponsored post

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Organizing Clinical Images in Dermatology

Do you find it difficult to keep track of your patient images when they come for follow up? Do you find it difficult to retrieve the right pictures for a conference presentation? Dermatology Image Tagger (DIT) is a free software to organize dermatology clinical pictures and to solve these problems.

DIT works by tagging images with patient ID, lesion, diagnosis, and date. You can search based on any of these tags! (Pictures of Mr. Smith, Pictures of psoriasis, etc.) The innovative feature is that the image file itself saves the tags but will not be visible on the display. So even if the image is copied to another computer, DIT will still be able to find it. [Download DIT FREE]

You can also share pictures with your friends, and they will be able to read these metadata using DIT. However, this introduces a security risk of inadvertently sharing this metadata on Facebook and other social media channels. To prevent the privacy risk, the tags are routinely encrypted with a password of your choice. If you share this password with your friends, they can view the tags.

I have hand coded it in Java and would be happy to hear feedback and feature requests. You can read about it and download it free from here: .[Just click the Facebook Like button to start download] This software made it into the ‘The Top 50 Tech Tools for Dermatology’ by DirectCapital. You can comment here for support tickets and feature requests!

See the instructions video below:

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Clinical Trial Assessment Scale for Cosmetic Dermatology

Clinical trials in cosmetic dermatology have some intrinsic limitations. Some of the prerequisites of an RCT such as blinding, allocation concealment and even randomization is difficult to achieve in cosmetic dermatology. Hence some of the well known scales for the methodological assessment of clinical trials such as Jadad and CONSORT have limited relevance in cosmetic clinical trial. Flawed evaluation of clinical trial quality allows flawed trials to thrive leading to clever new ways to distort trial results toward a favoured outcome.

Image Credit: By Evil Erin (

I have tried to enumerate well known biases in cosmetic dermatology and to put these ideas together as a framework for evaluating clinical trials in cosmetic dermatology. I have given it the acronym TASCDerm.

You can read more about TASCDerm and download a PDF score sheet from Dermatologists Sans Borders. [Click Here]


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Kudzu - Fair or not

Flowering kudzu is a fast-growing legume with ...
Flowering kudzu is a fast-growing legume with a grapelike odor. (Photo credit: Wikipedia)
First published in Dermatologists Sans Borders.

New herbal fairness agents are introduced every now and then though very few actually live up to the hype. However fairness industry is huge in most parts of Asia and research on new molecules always gets much attention. Most products of plant origin are introduced by cosmetic companies, and they often rely on old patents or anecdotal evidence of efficacy. Data on their effect on the melanin synthesis pathway is either not provided or deliberately hidden.

A new study (1) (open access. Link to the full paper below) demonstrates the effect of Kudzu, a group of plants in the genus Pueraria, in the pea family. It is well known that Kudzu is rich in isoflavones. The authors, using cell biology techniques, have demonstrated that the aerial part of P. thunbergiana can inhibit tyrosinase at the transcriptional level without cytotoxicity. In addition, it can also reduce tyrosinase maturation by inhibiting a-glucosidase.

Currently, numerous compounds are used for skin whitening, such as arbutin, hydroquinone, and kojic acid. Evidence suggests that the aerial part of P. thunbergiana, considered a weed in most parts of the world where it is seen, would one day be ranked higher in the list of depigmenting herbal products.

1. Han E, Chang B, Kim D, Cho H, Kim S. Melanogenesis inhibitory effect of aerial part of Pueraria thunbergiana in vitro and in vivo. Arch Dermatol Res. 2015 Jan;307(1):57-72. Epub 2014 Jul 26. PubMed PMID: 25063049; PubMed Central PMCID: PMC4282881.

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Patient-reported outcome instruments for facial lines

The questionnaire we used to select patients.
The questionnaire we used to select patients. (Photo credit: Wikipedia)
It is often difficult to achieve an objective definition of beauty. It is even more difficult to assess the self-perception of beauty at a cognitive level. Though FDA often does not get involved much in the realm of cosmetic dermatology, Botox(R) is indeed a different matter as it is an injectable with real medical indications. Do upper facial lines (UFL) cause enough psychological morbidity to justify intervention? FDA might ask for real evidence and we better be ready.

To prove the impact of UFL treatment, first of all we need a validated tool. FDA recommends patient-reported outcome instruments or PRO as objective evidence. PRO as defined by FDA

is any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.

One of the PRO instruments available for upper facial lines is the FLO-11 questionnaire. But unfortunately FLO-11 is not validated to the FDA standards. You don’t usually find many good qualitative studies in cosmetic dermatology. But this study (1) stands apart and has been quite methodical in validating the FLO-11 questionnaire.

Yet another study in the same journal (2) presents another questionnaire called Aesthetic Dermatology and Emotional Well-being (DEBIE), designed to know the general population motivations with regard to skin appearance. Though DEBIE is quite long, the authors have done a good job in validating the questionnaire using qualitative research principles. An abridged version may be more practical.

Both these questionnaires will be useful for those planning patient satisfaction studies in cosmetic dermatology. All we need now is proof. Botulinum Toxin for UFL is fortunately our best shot at objective proof.

Read More

1. Yaworsky A, Daniels S, Tully S, Beddingfield F 3rd, Kowalski J, Fitzgerald K, Somogyi C, Burgess SM. The impact of upper facial lines and psychological impact of crow’s feet lines: content validation of the Facial Line Outcomes (FLO-11)
Questionnaire. J Cosmet Dermatol. 2014 Dec;13(4):297-306. doi: 10.1111/jocd.12117. PubMed PMID: 25399622.  ↩

2. Martínez-González MC, Martínez-González RA, Guerra-Tapia A. Aesthetic dermatology and emotional well-being questionnaire. J Cosmet Dermatol. 2014
Dec;13(4):336-45. doi: 10.1111/jocd.12109. PubMed PMID: 25399627. ↩

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Dermatoscopy and The Ethics Report 2014

A recent study 1 from India has identified dermoscopic signs of evolving lesions of vitiligo. Authors observed reduced pigmentary network, absent pigmentary network, reversed pigmentary network, perifollicular hyperpigmentation and perilesional hyperpigmentation in the evolving vitigo lesions; a white glow was present in 27 (90%) of 30 patients. It is interesting to note that reversed pigmentary network, a well-known finding in dermatoscopy of melanoma and melanocytic nevus was also noted in many cases of evolving vitiligo. The authors conclude that dermoscopy scores over routine histopathology in the diagnosis of evolving lesions of vitiligo and can obviate the need for a skin biopsy in doubtful cases.

Image: Reversed Pigmentary Network in evolving lesions of vitiligo. (Image Credit Dr Sarvesh Thatte)

Skin Pathergy Test (SPT) – hypersensitivity of the skin to minimal trauma – is used as a diagnostic test in Behçet’s Disease with doubtful specificity. It is usually performed over the forearm with a blunt, sterilized needle. This article 2 recommends dermatoscopy for identifying sub-clinical pathergy reaction. The clinical relevance would have been much bigger if dermoscopy could replace biopsy in identifying pathergy. The authors have not clearly established the utility of dermoscopy in SPT. Authors have also mentioned about the significance of Thrombomodulin (TM) in pathergy. Thrombomodulin (TM) is a membrane-bound receptor of thrombin on vascular endothelial cells, which activates protein C and inactivates thrombin. High blood levels of TM were strongly correlated with positive skin pathergy test (SPT), suggesting that this test could be an alternative to the SPT.

  1. Thatte Sarvesh S, Khopkar Uday S. The utility of dermoscopy in the diagnosis of evolving lesions of vitiligo. Indian journal of dermatology, venereology and leprology 2014;80(6):505-508.
  2. Scherrer Maria A, Castro Lúcia P, Rocha Vanessa B, Pacheco Leonardo. The dermatoscopy in the skin pathergy testing: case series in patients with suspected behçet’s disease. Revista brasileira de reumatologia (english edition) 2014;54(6):494-498.
Medscape published the results of a survey conducted on over 21,000 global physicians, who answered the most wrenching ethical questions in medicine. Find out the changing opinions on controversial issues. Share your views on these issues with a comment below.

[Link to the report]

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About Me

As a Dermatologist and Informatician my research mainly involves application of bioinformatics techniques and tools in dermatological conditions. However my research interests are varied and I have publications in areas ranging from artificial intelligence, sequence analysis, systems biology, ontology development, microarray analysis, immunology, computational biology and clinical dermatology. I am also interested in eHealth, Health Informatics and Health Policy.


Bell Raj Eapen
Hamilton, ON